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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ' <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made,to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> HBusiness Name (DBA) tf Address <br /> ? Owner Address <br /> a <br /> 0-Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required IMormalion t t `-..Uw 3 SE, I`u 'JL"4 Ci{ JLltti ivt <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 So. Oro 4L Stockton, Calif. 95205 --- <br /> For July 1, June 30, 19 It Disposal Sites <br /> Ph.463-3209 <br /> r �1 <br /> Description(Make/Yr., Color) <br /> Serial No. i I CAL. License No. CAL. License Renewal No. <br /> t• j'j <br /> Capacity Gal.;Weights & Measures No. <br /> Equipment Parking Address <br /> f; 2. ❑ PUMPER YARD - <br /> For July 1, June 30, 19 - <br /> No. of Vehicles Stored I <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ` <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> t <br /> Test Location I Test Date/Time <br /> 4. A SANITATION PE IT f,p <br /> Job Add s�s/Lo�caation <br /> ` ,Owner Address <br /> SEPTIC TANK ❑ CESSPOOL - ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> © PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 !ADO <br /> Type Construction r Disposal Site V <br /> k <br /> No. of Units Equipment Storage/Cleaning Locations} <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft:, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> E <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an d regulations of.the San Joa in Local ealth District. <br /> --� Li.RKE CE'S SEPTIC & 5EV"ER SERVICE <br /> APPLICANT'S SIGNATURE X 0. Uro. #t t0Ckton, Calif. 95205 <br /> Ph.463-3209 Contractor's Lic.9267171 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE [].EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> I BILLING REMITTANCE $ REMIT <br /> `. BASE !EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> F I AMOUNT <br /> FEE <br /> Lyse <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHERANA, <br /> .� <br /> 1 <br /> - Received by Date I Receipt No. Permit No. Issuance Dat Mailed Delivered _ <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTALHEALTHPERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />